What are the responsibilities and job description for the Case Management Rep position at Houston Methodist?
JOB SUMMARY
At Houston Methodist, the Case Management (CM) Representative position provides technical, clerical assistance and data management support to the case management and social work department staff to facilitate efficient utilization of resources and discharge planning including referrals management, communication and collaboration with post-acute care providers, access to agencies and other community resources and transportation. This position may perform some secretary duties and performs a wide variety of administrative duties of a higher complexity in support of Case Management operations. In addition, the CM Rep position performs independent actions necessary to provide competent and professional assistance to meet the needs of social workers/case managers and patients. This position also coordinates, oversees, records and transmits information pertinent to the resource management of patients to next level of care providers.
PRIMARY JOB RESPONSIBILITIES
PEOPLE - 25%
- Serves as a department resource for questions related to case management activities. Communicates in an active, positive and effective manner to all interprofessional health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner. Answers telephones, troubleshoots and directs call to appropriate individuals, listens and responds to others. (EF)
- Facilitates and arranges acquisition of post-acute care needs, as directed, confirming with social workers and case managers, based on physician orders, payor/reimbursement practices and regulations that may impact the patient's plan of care. (EF)
- Maintains continuous communication with referring care coordinators, nurses, CM/SW or other clinical team members to keep them informed of the status of their request. (EF)
SERVICE - 30%
- Assists patients/families with documentation for Medical/Provider/Financial Assistance applications and pre-admissions questionnaires and answers patient questions on the process. (EF)
- Distributes the Medicare Notice of Discharges to identified patients, including capturing patient and their legal representative's signatures, answering any questions regarding the appeal process. (EF)
- Provides necessary transfer/admission documentation as necessary. Reviews for accuracy and completion. (EF)
- Assists with clerical and clinical functions for patients, physicians and staff. Provides administrative support as needed, including scheduling follow-up appointments. (EF)
- Confers with care coordinators and social workers to prioritize placement requests. (EF)
QUALITY/SAFETY - 10%
- Participates in quality improvement initiatives and collects data for use in departmental performance improvement as directed. Maintains timelines for follow up and prioritization of department projects and tasks. (EF)
FINANCE - 30%
- Informs social worker/case manager of the patients' available benefits through insurance/managed care provider. Assists in providing Community resources/services to uninsured patients as requested Case Management Staff. (EF)
- Participates in reimbursement/certification and authorization-related activities as directed. Documents approvals and authorization numbers from payors. Logs communications and provides information to social workers and case managers, business office/patient access, etc. on insurance/managed care benefits. (EF)
- Supports and assists with concurrent insurance denials and appeals process, transmission of utilization reviews to insurance companies as necessary, and documentation of authorization, approvals and denials. (EF)
- Provides information to patients/families on insurance/managed care benefits and assesses need for further education by social worker/case manager. (EF)
- Self-motivated to independently manage time effectively and prioritize daily tasks. Provides input into the department resource utilization including capital and operational budget needs as appropriate. (EF)
GROWTH/INNOVATION - 5%
- Maintains awareness of payor/reimbursement practices and regulations that may impact patient's plan of care and confers with care coordinators and social workers to prioritize placement requests. (EF)
This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
EDUCATION REQUIREMENTS
- High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)
- Associates degree preferred
EXPERIENCE REQUIREMENTS
- Five (5) years of combined work experience in insurance verification, working with patient information, having patient contact and/or general health care coordination responsibilities within a healthcare environment
- Previous experience in hospital setting and/or Case Management
